Does insurance cover occupational therapy? Mostly, the answer is “yes,” but in many cases, coverage often comes with certain conditions or limits.
What Is Occupational Therapy?
Occupational therapy helps enable patients to do everyday, common activities. It focuses on daily functions, work routines, and social pursuits to improve patients’ quality of life and independence.
Many patients go to occupational therapy when recovering from an injury or other medical problem. For example, an artist who suffers a hand injury may engage in tasks to regain their motor skills. Or an occupational therapist might help a stroke survivor relearn how to cook, eat, and groom themselves.
Occupational therapy also helps patients with chronic pain or long-term conditions. It can be useful for ADHD, autism, sensory issues, and some mental health problems. Occupational therapists can even help people succeed in social and academic settings.
Do Insurers Cover Occupational Therapy?
Although insurers typically cover some occupational therapy costs, your policy likely has certain conditions or limits. The extent of your coverage depends on the following factors:
What type of insurance plan you have
Whether your doctor determines the therapy is medically necessary
Whether your occupational therapist is in-network or out-of-network
How much your copayment and deductible are
How many sessions your insurer will cover
Before you schedule a session, it’s crucial to know what portions of the therapy your insurer covers and what those limits are.
Possible Conditions and Limits of Occupational Therapy Coverage
Most insurance companies cover certain costs associated with occupational therapy, such as:
First assessment and evaluations
Ongoing treatment sessions
Adaptive equipment, like canes, braces, or splints
Education or consultation
Progress monitoring
However, insurers may impose requirements or restrictions on occupational therapy before they approve coverage. Just a few of these conditions include the following:
Necessity
The most important factor is whether occupational therapy is needed and will help you. Insurers don’t cover treatments that don’t work. Your insurer may need confirmation from your doctor that occupational therapy is necessary. It may need to be assured that recovery is a realistic goal.
You may need preauthorization from your insurance company before you start treatment. Your insurer also may need to see your diagnosis code, an alphanumeric string assigned to your exact health condition.
In-Network
Most insurers want their customers to use medical providers from approved networks. This also applies to occupational therapy coverage. Using an in-network provider generally helps control costs and broaden coverage.
An out-of-network provider must be vetted and approved by your insurance company — if your policy even allows for this coverage. If it does, you might have a higher copayment.
Deductibles and Copayments
Many insurance plans — medical or otherwise — may require clients to cover deductibles before coverage kicks in. Your policy will list copayments for specific types of prescriptions or treatments. Occupational therapy may also be subject to these out-of-pocket expenses.
There’s a chance your insurer may offer full coverage for occupational therapy. But in many scenarios, deductibles and copayments will come into play.
Coverage Limits
Your insurer may impose some limits on your treatment. For example, it might limit the total number of treatment sessions. Or it might institute an annual dollar limit for reimbursement.
Progress Reports
After coverage begins, your insurer may ask for regular updates on your treatment progress. These reports may document your occupational therapist’s or doctor’s assessment of your improvement.
Your insurance company might ask for information about future treatments, updates to the treatment plan, immediate prognoses, and how the treatment relates to your diagnosis code.
How Do I Know if My Insurer Covers Occupational Therapy?
There are a few ways to determine whether your insurance company will cover occupational therapy. Of course, you can ask a provider about coverage before you enroll in a plan. But if that opportunity has passed, you can still find out whether your plan covers occupational therapy.
Review Your Policy Thoroughly
Take a very deep look into your written insurance plan. Your insurer’s occupational therapy policy may have its own section. However, it might be buried somewhere in the fine print.
Close examination of your health insurance plan is always a good idea. It’s an easy step to knowledge that many policyholders skip or don’t have time for. In this case, it will clear up your insurers’ approach to occupational therapy.
Call Your Insurer
When in doubt, give your insurer a call. A more user-friendly way of finding out about occupational therapy coverage is to speak to an insurance company representative.
Ask the representative, “Is occupational therapy covered in my insurance plan?” They should know what type of coverage is included in your policy. They also have instant access to your plan and can explain your expected costs.
Having a conversation with an insurance representative will answer many of your questions about occupational therapy. You may even discover coverage you weren’t aware of and get some advice on finding a qualified occupational therapist.
Does Your Insurance Allow for Occupational Therapy?
Occupational therapy is a proven method of treating and managing physical and mental ailments. It’s helped many patients regain their independence and live better-quality lives. While most insurance companies cover occupational therapy sessions, they often impose restrictions or limits. Get clear on where your insurer stands before you start.
